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HomeMy WebLinkAbout04-04-2023City of Auburn Law Enforcement Officers and Firefighters Disability Board Tuesday, April 4, 2023 - 10:00 AM — *Virtual Meeting via ZOOM* Per the City of Auburn Resolution No. 5533, the City of Auburn meeting location for all Council, Board and Commission meetings is virtual until King County enters into Phase 3 of Governor Inslee's Safe Start (Washington's Phased Reopening) plan. To attend the Auburn LEOFF Disability Board meeting, virtually and/or telephonically, please click the link or enter the meeting ID into the Zoom app or call into the meeting at the phone number listed below. AGENDA CALL TO ORDER II. PUBLIC PARTICIPATION The Auburn LEOFF Disability Board meeting scheduled for Tuesday, April 4, 2023, at 10:00 a.m. will be held in person and virtually. Virtual Participation Link: To attend the meeting virtually please click the link below, enter the meeting ID into the Zoom app, or call into the meeting at the phone number listed. Join Zoom Meeting: https://zoom.us/i/96103717191 Meeting ID: 9610371 7191 One tap mobile: +12532158782„96103717191# US (Tacoma) Dial by your location: +1 253 215 8782 US (Tacoma) Find your local number: https://zoom.us/u/aburepnwMs III. AGENDA MODIFICATIONS IV. CITIZEN INPUT AND/OR CORRESPONDENCE This is the place on the agenda where the public is invited to speak to the LEOFF Board on any issue. The public can participate in -person or submit written comments in advance of the scheduled meeting. Participants can submit written comments via mail, fax, or email. All written comments must be received 24 hours prior to 10:00 a.m. on the day of the scheduled meeting and must be 350 words or less. Please mail written comments to: City of Auburn Attn: Terry Mendoza, LEOFF Board Secretary 25 W Main St Auburn, WA 98001 Please fax written comments to: Attn: Terry Mendoza, LEOFF Board Secretary Fax: (253) 288-4305 Please email written comments to: tmendoza(cDauburnwa.aov V. APPROVAL OF MINUTES A. Minutes of the March 7, 2023, LEOFF Board Meetinq* VI. UNFINISHED BUSINESS LEOFF Board Agenda April 4, 2023 Page 1 City of Auburn Law Enforcement Officers and Firefighters Disability Board Tuesday, April 4, 2023 - 10:00 AM — *Virtual Meeting via ZOOM* A. Pendinq Medical/HearinaNision/Dental Claims VII. NEW BUSINESS A. Aimeals/Reauests for Reconsideration No appeal/request for reconsideration received. B. Medical/HearingNision/Dental Claims 1. LEOFF 1 Member #310533 Requests approval of dental expenses in the amount of $3,287.24 for services received on February 28, 2023. 2. LEOFF 1 Member #230947 Requests approval of dental expenses in the amount of $1,387.00 for services received on March 20, 2023. 3. LEOFF 1 Member #378501 Requests approval of dental expenses in the amount of $2,135.70 for services received on January 11 and March 16, 2023. C. Other Discussion VIII. ADJOURNMENT LEOFF Board Agenda April 4, 2023 Page 2 j ' 1 City of Auburn Law Enforcement Officers and Firefighters Disability Board Tuesday, March 7, 2023 -10:00 AM — *Virtual Meeting via ZOOM* Per the City of Auburn Resolution No. 5533, the City of Auburn meeting location for all Council, Board and Commission meetings is virtual until King County enters into Phase 3 of Governor Inslee's Safe Start (Washington's Phased Reopening) plan. To attend the Auburn LEOFF Disability Board meeting, virtually and/or telephonically, please click the link or enter the meeting ID into the Zoom app or call into the meeting at the phone number listed below. MINUTES CALL TO ORDER Chair Jim Kelly called the meeting to order at 10:00 a.m. Present on the Zoom call included Chair Pro Tern Bill Petersen, Member Laatsch, Member/Councilmember Bob Baggett, Member/Deputy Mayor James Jeyaraj, and Sr. City Attorney Doug Ruth. Also included on the Zoom call and in -person (Conference Room 3, City Hall) was Board Secretary Terry Mendoza. Member/Deputy Mayor Jeyaraj joined the meeting at 10:08 a.m. due to technical difficulties. II. PUBLIC PARTICIPATION The Auburn LEOFF Disability Board meeting scheduled for Tuesday, March 7, 2023, at 10:00 a.m. will be held in person and virtually. Virtual Participation Link: To attend the meeting virtually please click the link below, enter the meeting ID into the Zoom app, or call into the meeting at the phone number listed. Join Zoom Meeting: httiDs://zoom.us/i/95072522915 Meeting ID: 950 7252 2915 One tap mobile: +12532158782„95072522915# US (Tacoma Dial by your location: +1 253 215 8782 US (Tacoma) Find your local number: htti)s://zoom.us/u/abFBBb6LOo Board Secretary Mendoza reported that there was no member from the public present at the meeting, either virtually or in person. III. AGENDA MODIFICATIONS There were no agenda modifications. IV. CITIZEN INPUT AND/OR CORRESPONDENCE This is the place on the agenda where the public is invited to speak to the LEOFF Board on any issue. The public can participate in -person or submit written comments in advance of the scheduled meeting. Participants can submit written comments via mail, fax, or email. All written comments must be received 24 hours prior to 10:00 a.m. on the day of the scheduled meeting and must be 350 words or less. Please mail written comments to: City of Auburn Attn: Terry Mendoza, LEOFF Board Secretary 25 W Main St LEOFF Board Minutes March 7, 2023 Page 1 City of Auburn Law Enforcement Officers and Firefighters Disability Board Tuesday, March 7, 2023 -10:00 AM — *Virtual Meeting via ZOOM* Auburn, WA 98001 Please fax written comments to: Attn: Terry Mendoza, LEOFF Board Secretary Fax: (253) 288-4305 Please email written comments to: tmendoza anauburnwa.gov Board Secretary Mendoza reported that there was no correspondence received from the public. V. APPROVAL OF MINUTES A. Minutes of the February 7, 2023. LEOFF Board Meetinq* Motion by Chair Pro Tem Petersen to approve the minutes as published. Second by Member Baggett. MOTION CARRIED UNANIMOUSLY. 4-0 VI. UNFINISHED BUSINESS A. Pendinq Medical/Hearinq/Vision/Dental Claims VII. NEW BUSINESS A. Appeals/Requests for Reconsideration No appeal/request for reconsideration received. B. Medical/Hearinq/Vision/Dental Claims 1. LEOFF 1 Member #406822 Requests approval of vision expenses in the amount of $45.00 for services received on February 1, 2023. Motion by Member Baggett to approve the claim as submitted. Second by Chair Pro Tern Petersen. MOTION CARRIED UNANIMOUSLY. 4-0 2. LEOFF 1 Member #310533 Requests approval of dental expenses in the amount of $135.00 for services received on February 8, 2023. Motion by Chair Pro Tern Petersen to approve the claim as submitted. Second by Member Baggett. MOTION CARRIED UNANIMOUSLY. 4-0 3. LEOFF 1 Member #629199 LEOFF Board Minutes March 7, 2023 Page 2 City of Auburn Law Enforcement Officers and Firefighters Disability Board Tuesday, March 7, 2023 -10:00 AM — *Virtual Meeting via ZOOM* Requests approval of dental expenses in the amount of $99.00 for services received on February 9, 2023. Motion by Chair Pro Tern Petersen to approve the claim as submitted. Second by Member Laatsch. MOTION CARRIED UNANIMOUSLY. 4-0 4. LEOFF 1 Member #523842 Requests approval of medical expenses in the amount of $1,680.00 for services received on January 23 — 31, 2023. Motion by Member Baggett to approve the claim as submitted. Second by Chair Pro Tern Petersen. MOTION CARRIED UNANIMOUSLY. 4-0 5. LEOFF 1 Member #562044 Requests approval of dental expenses in the amount of $1,441.30 for services received on February 2 and 7, 2023. Motion by Chair Pro Tern Petersen to approve the claim as submitted. Second by Member Laatsch. MOTION CARRIED UNANIMOUSLY. 4-0 6. LEOFF 1 Member #349135 Requests approval of dental expenses in the amount of $255.00 for services received on March 1, 2023. Motion by Member Baggett to approve the claim as submitted. Second by Chair Pro Tern Petersen. MOTION CARRIED UNANIMOUSLY. 4-0 7. LEOFF 1 Member #392099 Requests approval of vision expenses in the amount of $444.00 for services received on February 24, 2023. Chair Pro Tern Petersen abstained from this agenda item. Motion by Member Laatsch to approve the claim as submitted. Second by Member Baggett. MOTION CARRIED UNANIMOUSLY. 3-0 8. LEOFF 1 Member #970468 Requests approval of vision expenses in the amount of $120.00 for services received on February 16, 2023. LEOFF Board Minutes March 7, 2023 Page 3 City of Auburn Law Enforcement Officers and Firefighters Disability Board Tuesday, March 7, 2023 -10:00 AM — *Virtual Meeting via ZOOM* Chair Kelly abstained from this agenda item. Motion by Member Baggett to approve the claim as submitted. Second by Member Laatsch. MOTION CARRIED UNANIMOUSLY. 3-0 C. Other Discussion Board Secretary Mendoza advised the Board about a change to the regular meeting date in July due to the 4th of July holiday. Another reminder will be provided at the June meeting. VIII. ADJOURNMENT There being no further business to come before the Board, the meeting was adjourned at 10:10 a.m. JIM KELLY, Chairman TERRY MENDOZA, Board Secretary LEOFF Board Minutes March 7, 2023 Page 4 LEOFF 1 CLAIM FOR PAYMENT FORM P/A�RT 1: RETIREE (CLAIMANT)INFORMATION— 1N ,Name as First) Street Address City SEND CLAIMS TO: City of Auburn HR Dept. Attn: LEOFF Board Secretary 25 W Main St, Auburn, WA 980C i FIRE C POLICE ❑ Phone Number State, Zip Code Is this a change of address? Yes ❑ Now Email: � PART 2: DESCRIPTION OF BILL-- MEDICAL COY PRESCRIPTION ElDENTAaL 'VISION ❑ *Use additional page if needed f3f / C0-17% Description of Service(s) Received Da (sYof Se4ice Total Bill: $ 73 /, / Amount submitted to LEOFF Board: $ Insurance E06 attached? Yes ld No ❑ Payment receipt attached? Yes D- No ❑ Is this for a work -related injury or illness? Yes ❑ No @r Related to an accident? Yes ❑ No ❑/ Are you covered by any other insurance (other than Medicare and the City's insurance)? Yes ❑ No Other Insurance information (name of Insurance, Group #, address, etc.): PART 3: CERTIFICATION (for all claims) I certify that the above information is complete and accurate to the best of my knowledge. I expressly authorize any service provider who has treated me to furnish my medical records to the City of Auburn LEOFF Board or its designee. I consent to examination by any other medical professional that the Board may require. I understand that this consent is given only for the purpose of publishing my right to LEOFF 1 benefits. RETIREE (CLAIMANT) SIGNATURE DATE v ---------------The following section to be completed by LEOFF Board Secretary --------------- APPROVAL OF CLAIM ❑ DENIAL OF CLAIM ❑ -seebq I certify that the LEOFF Board has reviewed the request and made the above recommendation based on the documentation provided. LEOFF Board Representative (Designee) Signature DATE !-\_`0=F Boa rolzorrrs\Me..., ., -Rx-1a .Ia -V : r, Clan, ,_- n. R - ;7 q r , , (�'�DREW WDENTISTRY SHANE P. DREW, D.D.S. =,:rai Dentistry 1821 N Trekell RD, Ste #9 Casa Grande, AZ 85122 520.374.240E 2�Za� 23 bola), t i2-`� -c�^-I cJ0- ^� f 4-Vsi-, c,v. Q b -,� yjD S . STATEMENT OF SERVICES RENDERED 1\ Drew Dentistry 1821 N Trekell Rd #9 Casa Grande, AZ 85122 (520)374-2400 GUARANTOR NAME AND MAILING ADDRESS Coy (Frank) Grall 2263 N Trekell Rd Lot 73 Casa Grande, AZ 85122 CHART NO. PAGE NO. GR0005 1 BILLING DATE 02/28/2023 PATIENT TOOTH SURF DESCRIPTION CHARGE CREDIT Coy (Frank) 12 Guided tiss regen-resorb-per 800.00 Coy (Frank) 12 Surg place implant: endosteal 1940.62 Coy (Frank) 12 Bone Graft, Implant Placement 400.00 Coy (Frank) 12 Extract,erupted th/exposed rt 146.62 Coy (Frank) Visa/MC Payment - Thank You -3287.24 Drew Dentistry 1821 N Trekell Rd #9 Casa Grande, AZ 85122 Tuesday, February 28, 202311:30:03 Patient Name Type Account Card Number Order ID Reference Number Grail, Coy (Frank) SALE VISA ****"**""`*" 9454 94532-91128-022023 1152972617 AMOUNT $3,287.24 App Preferred Name Visa Credit EMV AID A000000O031010 TC C10EC9C944CB6D22 Entry Contacticc Response Code 00/Approved Approval Number 00711A APPROVED - THANK YOU Signature IMPORTANT - retain this copy for your records *** Cardholder Copy *** �IMP - r 4y .y- a 5. s z ova r q ��� SEND CLAIMS TO: City of Auburn HR Dept. LEOFF 1 CLAIM FOR PAYMENT FORM Attn: LEOFF Board Secretary 25 W Main St, Auburn, WA 98001 PART 1: RETIREE (CLAIMANT) INFORMATION-- FIREL' POLICE ❑ Na (Last, • st) _ honer Street Address City F State, Zip Code Is this a change of address? Yes ❑ No Email: PART 2: DESCRIPTION OF BILL-- MEDICAL ❑ PRESCRIPTION ❑ DENTAL VISION ❑ *Use additional page if needed Description of Service(s) Received t: Date(s) of Service Total Bill: S Y/ J O 71 _'16 Amount submitted to LECH Board: $ o 7' '3c� *NOTE: All required back-up documentation must be provided/included with this claim form. Insurance EOB attached? Yes El No al_ Payment receipt attached? Yes No ❑ Is this for a work -related injury or illness? Yes ❑ No lam' Related to an accident? Yes ❑ No iU/ Are you covered by any other insurance (other than Medicare and the City's insurance)? Yes ❑ No13/ Other Insurance information (name of Insurance, Group #, address, etc.): 0 a" PART 3: CERTIFICATION (for all claims) I certify that the above information is complete and accurate to the best of my knowledge. I expressly authorize any service provider who has treated me to furnish my medical records to the City of Auburn LEOFF Board or its designee. I consent to examination by any other medical professional that the Board may require. I understand that this consent is given only for the purpose of establishing my right to LEOFF 1 benefits. % A Cc -__ 004-.'s.s, RETIREE (CLAIMANT) SIG TURE DATE The following section to be completed by LEOFF Board Secretary --------------- APPROVAL OF CLAIM ❑ DENIAL OF CLAIM ❑ -See backpagefor reason I certify that the LECH Board has reviewed the request and made the above recommendation based on the documentation provided. LEOFF Board Representative (Designee) Signature DATE C:\Users\tmendoz\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\Y70E61E3\Medical-Rx-Dental-Vision Claim Form Rev070219.docx Jonathan R Bayne, D.D.S., P.C. PO Box 796, 207 N. West St. Woodland Pk, CO 80866 1(719)687-6225 ACCOUNT NAME AND ADDRESS Theodore Lindback PO Box 521 Lake George, CO 80827 PATIENT CODE DESCRIPTION Ted 2740 crown-porcelain/ceramic Ted 50 Professional Discount Ted 3 Payment -Check -Thank You STATEMENT OF SERVICES RENDERED Monday March 20, 2023 ACCOUNT NUMBER 194400 STATEMENT FOR PATIENT Ted Lindback TH. SURF. AMOUNT EST. INS 30 1,460.00 73.00CR 1,387.00(K PREVIOUS TODAY'S TODAY'S NEW PLEASE PAY PATIENT CHARGES PAYMENTS PATIENT THIS AMOUNT BALANCE BALANCE 0.00 1,387.00 1,387.00 0.00 0.00 Next Appt. Day Date 'Time Reason (** = Estimate) Wed April 5, 2023 01:00P Seat Crown _ Thu June I, 2023 11:00a Prophylaxis - Adult Thank you for visiting our office! Current Dental Terminology (CDT) (c) 2022 American Dental Association (ADA). All rights reserved. n T - T �v r a .Ap .,. R 1 S v i s SEND CLAIMS TO: LEOFF 1 CLAIM FOR PAYMENT FORM PART 1: RETIREE (CLAIMANT) INFORMATION-- FIRE ❑ Name (Last, First) Street Address Is this a change of address? Yes ❑ 1\171:� City of Auburn HR Dept. Attn: LEOFF Board Secretary 25 W Main St, Auburn, WA 98001 POLIC# Phone Number City State, Zip Code Email: �`! t1��'�/Y.i✓►�� PART 2: DESCRIPTION OF BILL-- MEDICAL ❑ PRESCRIPTION ❑ DENTA�VISION ❑ *Use additional page if needed Description of Servic9(s) Received Date(s) Service Total Bill: S Amount submitted to LEOFF Board: $ *NOTE: All required back-up documentation must be provided/included with this claim form. Insurance EOB attached? Yes ❑ N Payment receipt attached? Yes No ❑ �4 1k Is this for a work -related injury or illness? Yes ❑ No ❑ Related to an accident? Yes ❑ No Are you covered by any other insurance (other than Medicare and the City's insurance)? Yes ❑ No ' Other Insurance information (name of Insurance, Group #, address, etc.): PART 3: CERTIFICATION (for all claims) I certify that the above information is complete and accurate to the best of my knowledge. I expressly authorize any service provider who has treated me to furnish my medical records to the City of Auburn LEOFF Board or its designee. I consent to examination by any other medical professional that the Board may require. I understand that this coylsitnt is giv n ly for the purpose of establishing my right to LEOFF 1 benefits. R IRE E (C T) SI ATURE r6fE ---------------The following section to be completed by LEOFF Board Secretarv--------------- APPROVAL OF CLAIM ❑ DENIAL OF CLAIM ❑ *See bock pogefor reason I certify that the LEOFF Board has reviewed the request and made the above recommendation based on the documentation provided. LEOFF Board Representative (Designee) Signature DATE L:\LEOFF Board\Forms\Medical-Rx-Dental-Vision Claim Form Rev070219.docx January 11, 2023 John Calkins 3605 Shell St Greenbank, WA 98253 I D: 4028 Patient 1/11/2023 John John John John John John John Contract Balance $0.00 Freeland Family Dental PO Box 729 Freeland, WA 98249 (360)331-5211 Account Aging Current: 30 Days: 60 Days: 90 Days: Contract: Balance Due: Estimated Insurance: Balance Due Now: Provider Transaction TTth Surface Ashley Petosa, RDH D1110 - PROPHYLAXIS -ADULT (Standard Fee $133.00) (Adjust $0.00) (Fee $133.00) Kyle T. Fukano, D0120 - PERIODIC ORAL EVALUATION D.D.S. (Standard Fee $68.00) (Adjust $0.00) (Fee $68.00) Ashley Petosa, RDH D0274 - BITEWINGS-FOUR FILMS (Standard Fee $77.00) (Adjust $0.00) (Fee $77.00) Ashley Petosa, RDH D0220 - INTRAORAL-PERIAPICAL FIRST FILM 25 (Standard Fee $31.00) (Adjust $0.00) (Fee $31.00) Ashley Petosa, RDH D0230 - INTRAORAL-PERIAPICAL-EACH 8 ADDITIONAL FIL (Standard Fee $24.00) (Adjust $0.00) (Fee $24.00) Acct Pmt - Credit Card Credit Card Last4: 6904 for ($299.70) Credit Adj - Cash Discount for ($33.30) $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Em $133.00 $68.00 $77.00 $31.00 $24.00 SubTotal: $333.00 Tax: $0.00 Charge(s): $333.00 - Payment(s): $299.70 - Adjustment(s): $33.30 Previous Balance: $0.00 Balance Due: $0.00 Estimated Previous Charge(s) Payment(s) Adjustment(s) Balance Insurance Balance Due Now $0.00 $0.00 $333.00 $299.70 ($33.30) $0.00 Page 1 of 2 Current Dental Terminology (CDT) 0 American Dental Association (ADA). All rights reserved. Freeland Family Dental PO Box 729 Freeland, WA 98249 (360)331-5211 SIGNED I agree to pay the above payment amount according to my card issuer agreement. Future Family Appointments: Patient: Next Appointment: Patient: Next Appointment: Patient: Next Appointment: 4028 John Calkins 2/22/2023@ 1:OOpm 4028 John Calkins 3/16/2023@ 1:OOpm 4028 John Calkins 5/212023@ 3:OOpm 4028 John Calkins 9/5/2023@ 2:OOpm -Current Dental Terminoloov (CDTI Page 2 of 2 0 American Dental Association (ADA). Al rights reserved. Transaction Successful Transaction Receipt Merchant•' KYLE FUKANO DDS PLLC - (FREELAND, WA) Merchant Phone: 360-3315211 Date/Time: 01/11/2023 12:06:16 PM PST Transaction ID: 7965050314 Transaction Type: Card Sale Entry Method: Chip Card Cardholder Verification Method: Signature Verified Amount: $299.70 Credit Card Information CC Type: Mastercard CC Number: ************6904 EMV Application Label: MASTERCARD DEBIT Billing Information Cardholder Name: JOHN T CALKINS Additional Information Desk Location: Receptions Posted: YES Cardholder Authorization I agree to pay the above total amount according to card issuer agreement. Customer Signature Thank you for your business. Please keep this receipt for your records. March 16, 2023 John Calkins 3605 Shell St Greenbank, WA 98253 ID: 4028 Dak Patlen 3/16/2023 John John 2/22/2023 John John John John John 3/16/2023 John John Contract Balance $0.00 Provider Kyle T. Fukano, D.D.S. Kyle T Fukano, D.D.S. Kyle T. Fukano, D.D.S. Kyle T Fukano, D.D.S. Kyle T Fukano, D.D.S. Kyle T. Fukano, D.D.S. Kyle T. Fukano, D.D.S. Freeland Family Dental PO Box 729 Freeland, WA 98249 (360)331-5211 Account Aging Current: 30 Days: 60 Days: 90 Days: Contract: Balance Due: Estimated Insurance: Balance Due Now: Transaction TTth Surface D2335 - RESIN -FOUR OR MORE SURFACES, 7 MIFL ANTERIOR (Standard Fee $338.00) (Adjust $0.00) (Fee $338.00) CRNST-CROWN SEAT (Standard Fee $0.00) (Adjust $0.00) (Fee $0.00) D2950 - CORE BUILDUP, INCLUDING ANY PINS 11 (Standard Fee $329.00) (Adjust $0.00) (Fee $329.00) D2740-CROWN-PORCELAIN/CERAMIC 11 SUBSTRATE (Standard Fee $1,319.00) (Adjust $0.00) (Fee $1,319.00) TPST - Fluoride Tooth Paste (Standard Fee $18.00) (Adjust $0.00) (Fee $18.00) TPST - Fluoride Tooth Paste (Standard Fee $18.00) (Adjust $0.00) (Fee $18.00) TPST - Fluoride Tooth Paste (Standard Fee $18.00) (Adjust $0.00) (Fee $18.00) Credit Adj - Cash Discount for ($204.00) Acct Pmt - Credit Card Credit Card Last4: 6266 for ($1,836.00) Estimated Previous Charge(s) Insurance Balance $0.00 $0.00 $2,040.00 gurrent Dental Terminology (CDT) $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Ea $338.00 $0.00 $329.00 $1,319.00 $18.00 $18.00 $18.00 Payment(s) Adjustment(s) Balance Due Now $1,836.00 ($204.00) $0.00 Page 1 of 2 0 American Dental Association (ADA). All rights reserved. Contract Estimated Balance Insurance $0.00 $0.00 Future Family Appointments: Patient: Next Appointment: 4028 John Calkins 5/2/2023@ 3:OOpm Freeland Family Dental PO Box 729 Freeland, WA 98249 (360)331-5211 SubTotal: $2,040.00 Tax: $0.00 Charge(s): $2,040.00 - Payment(s): $1,836.00 - Adjustment(s): $204.00 Balance Due: $0.00 Previous Charge(s) Payment(s) Adjustment(s) Balance $0.00 $2,040.00 $1,836.00 ($204.00) Patient: Next Appointment: Patient: 4028 John Calkins 9/5/2023@ 2:OOpm Balance Due Now $0.00 Next Appointment: Page 2 of 2 .Current Dental Terminoloov K'Q11 0 American Dental Association (ADA). All rights reserved. Transaction Successful Transaction Receipt Merchant: KYLE FUKANO DDS PLLC - (FREELAND, WA) Merchant Phone: 360-3315211 Date/Time: 03/16/2023 1:01:23 PM PDT Transaction ID: 8158863262 Transaction Type: Card Sale Entry Method: Chip Card Cardholder Verification Method: Signature Verified Amount: $1,836.00 Credit Card Information CC Type: Visa CC Number: ************6266 EMV Application Label: VISA CREDIT Billing Information Cardholder Name: JOHN T CALKINS Additional Information Desk Location: Receptionl Posted: YES Cardholder Authorization I agree to pay the above total amount according to card issuer agreement. Customer Signature Thank you for your business. Please keep this receipt for your records.